Provider First Line Business Practice Location Address:
3931 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST CHICAGO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-397-4071
Provider Business Practice Location Address Fax Number:
219-397-2051
Provider Enumeration Date:
09/06/2012